Anthem Blue Cross Blue Shield of California prior authorization, page 42
CPT code lookup
Each row is one code from the public prior authorization list. The description is the procedure or service name on that source row. This is not a coverage decision.
Prior authorization codes
| Code | Description | Source |
|---|---|---|
| 43192 | Esophagoscopy, rigid, transoral; with directed submucosal injection(s), any substance [when specified as injection of bulking agent] | California PPO Prior Authorization List, Pg 102 Original policy |
| 43201 | Esophagoscopy, rigid or flexible; with directed submucosal injection(s), any substance [when specified as injection of bulking agent] | California PPO Prior Authorization List, Pg 102 Original policy |
| 43210 | Esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed | California PPO Prior Authorization List, Pg 102 Original policy |
| 43233 | Esophagogastroduodenoscopy, flexible transoral; diagnostic, with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed) | California PPO Prior Authorization List, Pg 102 Original policy |
| 43235 | Esophagogastroduodenoscopy, flexible transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) | California PPO Prior Authorization List, Pg 102 Original policy |
| 43236 | Esophagogastroduodenoscopy, flexible transoral; with directed submucosal injection(s), any substance [other than injections related to gastroesophageal reflux or dysphagia] | California PPO Prior Authorization List, Pg 102 Original policy |
| 43239 | Esophagogastroduodenoscopy, flexible transoral; with biopsy, single or multiple | California PPO Prior Authorization List, Pg 102 Original policy |
| 43241 | Esophagogastroduodenoscopy, flexible transoral; with insertion of intraluminal tube or catheter | California PPO Prior Authorization List, Pg 102 Original policy |
| 43243 | Esophagogastroduodenoscopy, flexible transoral; with injection sclerosis of esophageal/gastric varices | California PPO Prior Authorization List, Pg 102 Original policy |
| 43244 | Esophagogastroduodenoscopy, flexible transoral; with band ligation of esophageal/gastric varices | California PPO Prior Authorization List, Pg 102 Original policy |
| 43245 | Esophagogastroduodenoscopy, flexible transoral; with dilation of gastric/duodenal stricture(s) (e.g., balloon, bougie) | California PPO Prior Authorization List, Pg 102 Original policy |
| 43246 | Esophagogastroduodenoscopy, flexible transoral; with directed placement of percutaneous gastrostomy tube | California PPO Prior Authorization List, Pg 102 Original policy |
| 43247 | Esophagogastroduodenoscopy, flexible transoral; with removal of foreign body(s) | California PPO Prior Authorization List, Pg 102 Original policy |
| 43248 | Esophagogastroduodenoscopy, flexible transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire | California PPO Prior Authorization List, Pg 102 Original policy |
| 43249 | Esophagogastroduodenoscopy, flexible transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter) | California PPO Prior Authorization List, Pg 102 Original policy |
| 43250 | Esophagogastroduodenoscopy, flexible transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps | California PPO Prior Authorization List, Pg 102 Original policy |
| 43251 | Esophagogastroduodenoscopy, flexible transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique | California PPO Prior Authorization List, Pg 103 Original policy |
| 43254 | Esophagogastroduodenoscopy, flexible transoral; with endoscopic mucosal resection | California PPO Prior Authorization List, Pg 103 Original policy |
| 43255 | Esophagogastroduodenoscopy, flexible transoral; with control of bleeding, any method | California PPO Prior Authorization List, Pg 103 Original policy |
| 43257 | Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease | California PPO Prior Authorization List, Pg 103 Original policy |
| 43266 | Esophagogastroduodenoscopy, flexible transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) | California PPO Prior Authorization List, Pg 103 Original policy |
| 43281 | Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh | California PPO Prior Authorization List, Pg 103 Original policy |
| 43282 | Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; with implantation of mesh | California PPO Prior Authorization List, Pg 103 Original policy |
| 43497 | Lower esophageal myotomy, transoral (i.e., peroral endoscopic myotomy [POEM]) | California PPO Prior Authorization List, Pg 103 Original policy |
| 43889 | Gastric restrictive procedure, transoral, endoscopic sleeve gastroplasty (ESG), including argon plasma coagulation, when performed | California PPO Prior Authorization List, Pg 103 Original policy |
| 45378 | Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) | California PPO Prior Authorization List, Pg 103 Original policy |
| 45380 | Colonoscopy, flexible; with biopsy, single or multiple | California PPO Prior Authorization List, Pg 103 Original policy |
| 45384 | Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps | California PPO Prior Authorization List, Pg 103 Original policy |
| 45385 | Colonoscopy, flexible; with removal of tumor(s), polyps(s), or other lesion(s) by snare technique | California PPO Prior Authorization List, Pg 103 Original policy |
| 45388 | Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) | California PPO Prior Authorization List, Pg 103 Original policy |
| 45560 | Repair of rectocele | California PPO Prior Authorization List, Pg 103 Original policy |
| 51715 | Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck | California PPO Prior Authorization List, Pg 103 Original policy |
| 51721 | Insertion of transurethral ablation transducer for delivery of thermal ultrasound for prostate tissue ablation, including suprapubic tube placement during the same session and placement of an endorectal cooling device, when performed | California PPO Prior Authorization List, Pg 103 Original policy |
| 53445 | Insertion of inflatable urethral/bladder neck sphincter, including placement of pump, reservoir, and cuff | California PPO Prior Authorization List, Pg 103 Original policy |
| 53446 | Removal of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff | California PPO Prior Authorization List, Pg 103 Original policy |
| 53447 | Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff at the same operative session | California PPO Prior Authorization List, Pg 104 Original policy |
| 53449 | Repair of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff | California PPO Prior Authorization List, Pg 104 Original policy |
| 53451 | Periurethral transperineal adjustable balloon continence device; bilateral insertion, including cystourethroscopy and imaging guidance [ProACT System] | California PPO Prior Authorization List, Pg 104 Original policy |
| 53452 | Periurethral transperineal adjustable balloon continence device; unilateral insertion, including cystourethroscopy and imaging guidance [ProACT System] | California PPO Prior Authorization List, Pg 104 Original policy |
| 53453 | Periurethral transperineal adjustable balloon continence device; removal, each balloon [ProACT System] | California PPO Prior Authorization List, Pg 104 Original policy |
| 53454 | Periurethral transperineal adjustable balloon continence device; percutaneous adjustment of balloon(s) fluid volume [ProACT System] | California PPO Prior Authorization List, Pg 104 Original policy |
| 53860 | Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence | California PPO Prior Authorization List, Pg 104 Original policy |
| 54400 | Insertion of penile prosthesis; non-inflatable (semi-rigid) | California PPO Prior Authorization List, Pg 104 Original policy |
| 54401 | Insertion of penile prosthesis; inflatable (self-contained) | California PPO Prior Authorization List, Pg 104 Original policy |
| 54405 | Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir | California PPO Prior Authorization List, Pg 104 Original policy |
| 54410 | Removal & Replacement, Multi-Component Inflatable Penile Prosthesis, Same Session | California PPO Prior Authorization List, Pg 104 Original policy |
| 54411 | Removal & Replacement, Multi-Component Inflatable Penile Prosthesis, Infected, W/ Irrig & Debride | California PPO Prior Authorization List, Pg 104 Original policy |
| 54416 | Removal & Replacement, Non-Inflatable (Semi- Rigid)/Inflatable (Self-Contained) Penile Prosthesis | California PPO Prior Authorization List, Pg 104 Original policy |
| 54417 | Removal & Replace, Non-Inflatable/Inflatable Penile Prosthesis Infect, W/Irrig & Debride | California PPO Prior Authorization List, Pg 104 Original policy |
| 55860 | Exposure, Prostate, Any Approach, Radiation Insertion | California PPO Prior Authorization List, Pg 104 Original policy |